CHECK LIST (FRESH APPLICATION)

1. Name of the Student :

2. Name of the Institution :

3. Course of Present Study :

4. Category : SC / ST / OBC / MBC / General

5. Phone/Cell No. : E.mail I.D. :

6. Aadhar No. :

(FOR DIRECTORATE OF HIGHER AND TECHNICAL EDUCATION OFFICE USE ONLY)

7. Copy of CENTAC Selection Order : Enclosed / Not enclosed

8. Self Affidavit : Enclosed / Not enclosed

9. Caste Certificate (In case of SC / ST / OBC / MBC) : Enclosed / Not enclosed

10. Higher Secondary (+2) Mark List : Enclosed / Not enclosed

11. Application duly filled in : Enclosed / Not enclosed

12. Nationality and Residence Certificate : Enclosed / Not enclosed

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13. Attested copy of 1 page of Bank Pass Book / Account : Enclosed / Not enclosed
Statement

SIGNATURE OF DEALING ASSISTANT SIGNATURE OF SECTION HEAD

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 APPLICATION FOR AWARD OF PERUNTHALAIVAR KAMARAJAR FINANCIAL
ASSISTANCE TO 1ST YEAR / II YEAR (LATERAL ENTRY) STUDENTS
FORWARDING CERTIFICATE

(This certificate should not be filled-in by the applicant. It should be filled-in by the Head of the Institution
in which the applicant is a student in 20 - 20 )

1. Name of the student (in BLOCK LETTERS) :

2. Name of the Examination Passed :

3. Name of Father / Guardian :

4. Class to which admitted {I Year / II Year (Lateral Entry)} :

5. CENTAC No. and Year :

(A copy of the CENTAC selection order to be enclosed)
6. Year of Admission :

7. The date on which the student joined the institution for the : Date Month Year
academic year 20 - 20

8. Year of passing :

9. Marks secured by the student and maximum marks :

10. Percentage of marks :

11. Community :
(Copy of the Community certificate to be enclosed in the
case of SC/ST/MBC/OBC)
12. The month and year in which the Annual University :
Examination will be ordinarily be over for the present
class
13. Student Bank A/c Details
(a) Name of the Bank & Branch :

(b) Bank Account No. :

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(Attested copy of the 1 Page of Bank Pass Book (or
Statement of A/c should be enclosed)

Certified that the particulars furnished above have been verified by me and found correct.
The application form has been scrutinized and found to be in order and the candidate deserves to avail
financial assistance.

Place :

Signature of the Principal / Registrar

Date :
(Office Seal)
 CHECK LIST FOR SCRUTINY OF APPLICATIONS FOR THE AWARD OF
PERUNTHALAIVAR KAMARAJAR FINANCIAL ASSISTANCE TO THE STUDENTS

STUDYING __________________________________________________ COURSE

1. Name of the student (in BLOCK LETTERS) :

2. Class :

3. Name of the Institution where studying at present :

4. Qualifying Examination :

5. Total aggregate marks :

6. Percentage obtained in the above examination :

7. Whether the applicant is already in receipt of any other :

Scholarships, i.e. National Scholarship Scheme /
Pondicherry State Post-Matric Scholarship / Scholarship
from A.D. Welfare Department.
8. Whether the following enclosures attached to the
application

(i) Attested copy of the mark sheets for the last Board / :
University Examination

(ii) Community, Nationality and Residence Certificates :

9. Whether all the columns of the application duly filled in or :
not

10. Remarks :

Signature of the Head of the Institution

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 ANNEXURE I
(Rule IV)

APPLICATION FORM FOR PERUNTHALAIVAR KAMARAJAR FINANCIAL ASSISTANCE TO

THE STUDENTS STUDYING ___________________________________________ COURSE

I. Each item should be read carefully before the form is filled in.
No change will be permitted after the application has been submitted.
If any entry is found to be incorrect, the Financial Assistance, if
awarded, will be liable to be cancelled forthwith. Passport size
photograph to be
pasted here
II. Incomplete statement or statements received after the prescribed
date will not be considered.

1. Name in full stating whether Shri / Smt. / Kum. :

(in BLOCK LETTERS)

2. (a) Exact date of Birth (In Christian era) : Date Month Year

(b) Place, District and State of Birth :

(c) Residential address of candidate :

3. Details of Parents Father Mother

:
(a) Name
:
(b) Nationality
:
(c) Whether alive
:
(d) Occupation

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5.. Particulars of School / College / Institution last attended

Name of School / College Date of Entry Date of Year Remarks, if any

Institution Leaving
(1) (2) (3) (4) (5)

6. (a) Name of the last examination passed :

(b) Year of passing :

(c) Name of the authority (Board or University) which :

conducted the examination taken by the applicant
together with the place of its headquarters

(d) Roll No. :

(e) Total number of marks for the examination as a whole :

including the marks in the Optional paper / papers, if
these are counted by Board, University in awarding
division (Attested copy of the marks sheet should be
attached)

(f) Percentage of marks obtained in the aggregate :

7. If the candidate is in receipt of any Scholarship or :

Scholarships from a State Government or any other
institution or persons, particulars should be given
including the monthly rate and date from which the
Scholarship is being drawn.
8. (a) Name and address of the institution where the :
Scholar has been admitted

(b) Course of Study :

(c) Duration of the Course :

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9. List of enclosures sent with the statement (please strike
out that which is not applicable)

(a) Attested copy of mark sheet for the last Board / :

University Examination

(b) Community, Nationality and Residence Certificate :

Certified that the statements made by me in this form is correct.

I declare that in case, I am selected for the Financial Assistance I shall devote my full time to the
course of study, and that I shall not received another Scholarship from any other source. I shall seek
permission from the Director of Higher and Technical Education in case I prefer to shift to another course
in future.

Place :

Date : Signature of the Student

COUNTERSIGNED

Signature of the Principal / Registrar

(Office Seal)

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 SELF AFFIDAVIT

(To be furnished in Stamped Paper worth Rs.5/-)

I, _________________________________ Son / Daughter of ___________________________ ,

Puducherry, under the Sponsored Quota of Government of Puducherry, hereby declare that the
information regarding Residence / Nativity furnished by me along with the applications for the Award of
Perunthalaivar Kamarajar Financial Assistance are true and correct.

Further, I declare that I shall devote my full time to the course of study for which I have applied /
received the Scholarship.

Further, I undertake in the event of particulars given in this declaration being found to be false or
become ineligible for receipt of the Financial Assistance I shall refund the double the amount of the
Financial Assistance received by me to the Government of Puducherry.

Place : Signature of the Student

Date : Name

Address

Witness 1. Name

Address

Witness 2. Name

Address